PH 210: Epidemiology for Public Health Practice

Dr. Grosskopf
Pre-Class Activity: Cohort and Case-Control Studies ANSWERS

1. A study in which investigators follow two or more groups of people over a period of time
to determine their incidence of disease. The individuals in each group are disease-free
at the start of follow-up and have a common characteristic (e.g., exposed and
unexposed).

2. A. Selection of comparison group participants: Experimental study investigators

generally use randomization to determine which individuals enter the comparison
group, while cohort study investigators select a group that is as similar as possible to
the exposed group. The aim with both methods is to eliminate confounding by making
the groups comparable.

B. Use of placebos: In experimental studies, placebos are used to make the

experience of participating in the study comparable between the treatment and
comparison groups. In cohort studies, we cannot use placebos, so we select as
comparable a comparison group as possible. In both cases, the goal is to maximize
the similarity between study groups in order to reduce confounding and bias.
C. Masking: Experimental studies can be single-masked or double-masked; in cohort
studies we can only mask the investigator. In both settings, the aim is to reduce bias
in outcome ascertainment.

3. For timing:
Retrospective cohort: both the exposure and the disease have already occurred at the
time the study starts.
Prospective cohort: the exposure has usually occurred, but the disease has not
occurred at the time the study starts.
Ambidirectional cohort: has both retrospective and prospective elements.
For feasibility:
Special cohort: assembled to study rare exposures such as occupational exposures or
unusual diets
General cohort: assembled to study common exposures; group is usually selected
because they are easy to follow and are likely to give accurate data. Usually selected
from a defined geographic area.
For population type:
Open or dynamic: assembled from an open or dynamic population that is defined on the
basis of a changeable characteristic. Members come and go.
Fixed: assembled from a fixed population that is defined on the basis of an irrevocable
event. Does not gain members but losses may occur.
Closed: assembled from a fixed population that is defined on the basis of an irrevocable
event. Does not gain or lose members.

4. Advantages of prospective studies: good data on exposures and confounders, less

vulnerable to bias.
Disadvantages: expensive, time-consuming, inefficient for diseases with long latent and
induction period.
 Advantages of retrospective studies: inexpensive, fast, efficient for diseases with long
latent and induction period.
Disadvantages: outcome and exposure data may be inadequate, information on
confounders may be missing.

5. Occupational groups, groups undergoing medical treatments, groups with unusual

diet/lifestyle, professional groups, students, alumni, residents in defined geographical
areas.

6. The comparison group should be as similar as possible to the exposed group with
respect to all relevant factors except the exposure itself. The ideal comparison group
would consist of exactly the same individuals in the exposed group had they not been
exposed. This theoretical concept is known as the counterfactual ideal. Since it is
impossible for the same person to be exposed and unexposed simultaneously,
epidemiologists must select different sets of people for the exposed and unexposed
groups.

7. Internal is considered the best, because it will be the most comparable. Selected from
same source population as exposed group.
Comparison cohort – From another similar but unexposed population.
General population – From readily available data from general population. Does not
have information on many confounders.

8. Pre-existing records:
Advantages: inexpensive, no potential for recall or information bias.
Disadvantages: level of detail may be inadequate or missing, information on
confounders may be missing.
Questionnaires, interviews:
Advantages: Designed specifically for the study so good information on
exposures, confounders, etc.
Disadvantages: recall bias if retrospective cohort.

9. Death certificates, medical records, questionnaires, interviews, medical exams.

10. Voter registration lists; telephone books and directory assistance, Internet resources;
birth, death, and marriage records; drivers' license records; hospital records; information
from relatives and friends.

11. Efficient for rare exposures; able to get good information on exposures, if prospective;
able to evaluate multiple effects of an exposure; efficient for diseases with long
induction and latent period, if retrospective; less vulnerable to bias, if prospective; clear
temporal relationship between exposure and disease outcome, if prospective;

12. A method of sampling a population in which cases of disease are identified and enrolled
and a sample of the population that produced the cases is also identified and enrolled.
Exposures are determined for individuals in each group.

13. A. When the disease is rare

 B. When little is known about the disease (can study multiple exposures)
C. When the population under study is dynamic (i.e. difficult to follow)
D. When the exposure data are expensive or difficult to obtain
E. When the disease has a long latent and induction period.

14. In order to avoid misclassification.

15. a. Existing registries, such as cancer registries

b. Hospitals, clinics
c. General population

16. Controls should be a sample of the population that gave rise to the cases and therefore
should have the same exposure distribution as this source population. Ask yourself: if a
member of the control group actually had the disease under study, would he/she end up as a
case in your study? The answer should be YES!

17. a. General population controls

advantages - sampling from the actual population that gave rise to the cases, likely to
have the exposure distribution of the source population that gave rise to the cases
disadvantages - time consuming, expensive, hard to contact and get cooperation, non-
diseased controls may remember exposures differently than cases (recall bias)
b. Hospital controls
advantages – If appropriate diseases are selected for inclusion, selection forces that led
cases to a particular hospital should also have led controls to same hospital. Easy to
identify, accessible, less expensive, exposure recall comparable to that of cases
because controls are also sick, more willing to participate.
disadvantages – Difficult to determine appropriate diseases for inclusion.
c. Special control groups such as friends, relatives, spouses of cases, dead controls
Advantages and disadvantages may depend on particular circumstances and the
control group chosen. For example, if cases nominated their "drinking buddies" as friend
controls in a study of alcohol use and cardiovascular disease, the results would be
biased towards the null.

18. Case-control studies are vulnerable to bias because both the exposure and disease have
already occurred when the study commences. Thus, knowledge of disease status may
influence selection and reporting of exposure status. Retrospective cohort studies are also
prone to bias for the same reason.

19. Recall bias and interviewer bias. Recall bias occurs when cases recall exposure differently
(either more or less accurately) than controls. Recall bias can be minimized by blinding the
subjects to the study hypothesis or by using hospital controls who are also sick. Interviewer
bias occurs when interviewers obtain exposure information differently for cases and controls.
This can be minimized by masking the interviewer to the study hypothesis and the case-control
status of the subject.

20. a. Efficient for rare diseases and diseases with a long induction and latent period.
b. Able to study several risk factors for the same disease - good when risk factors for
the disease are not well understood.
21. a. Inefficient for rare exposures
b. May have poor information on exposures because retrospective
c. More vulnerable to bias because retrospective
d. May be more difficult to infer temporal relationship between exposure and disease

22. They are the complement (opposite) of those usually associated with cohort studies.

23. We do not know the number of exposed and unexposed in the total population, so we
cannot calculate rates.